The new 2013 WHO Consolidated Guidelines on the Use of Antiretroviral Therapy (ART) make aspirational recommendations for ART delivery in low and middle income countries. Comprehensive assessments of available evidence were undertaken and the recommendations made are likely to improve individual health outcomes. However feasibility was downplayed, the Guidelines represent high-cost policy options not all of which are compatible with the core public health principles of decentralization; task-shifting; and a commitment to universality. Critically, their impact on equity and the population-level distribution of health outcomes were not fully considered. We analyze the likely distribution of health outcomes resulting from alternative ways of realising the 2013 Guidelines and assess practicality, feasibility and health attainment amongst different sections of the population in the context of financial and human resource constraints. Claim can be made that direct interpretation of the Guidelines follows a \"human rights\" based approach in seeking to provide individual patients with the best alternatives amongst those available on the basis of current evidence. However, there lies a basic conflict between this and \"consequentialist\" public health based approaches that provide more equal population-level outcomes.When determining how to respond to the 2013 Guidelines and fairly allocate scarce lifesaving resources, national policymakers must carefully consider the distribution of outcomes and the underpinning social value judgements required to inform policy choice. It is important to consider whose values should determine what is a just distribution of health outcomes. The WHO Guidelines committees are well placed to compile evidence on the costs and effects of health care alternatives. However, their mandate for making distributional social value judgements remains unclear.
Revill, P.; Asaria, M.; Phillips, A.; Gibb, D. M.; Gilks, C.F. WHO decides what is fair? International HIV treatment guidelines, social value judgements and equitable provision of lifesaving antiretroviral therapy. Centre for Health Economics, University of York, (2014)